Provider Demographics
NPI:1003392986
Name:VANTILBURG, DANIELLE
Entity Type:Individual
Prefix:MISS
First Name:DANIELLE
Middle Name:
Last Name:VANTILBURG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:541 1/2 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WELLSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43968-1653
Mailing Address - Country:US
Mailing Address - Phone:330-383-4457
Mailing Address - Fax:
Practice Address - Street 1:541 1/2 MAIN ST
Practice Address - Street 2:
Practice Address - City:WELLSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43968-1653
Practice Address - Country:US
Practice Address - Phone:330-383-4457
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-13
Last Update Date:2018-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0270467Medicaid
OH0270467Medicaid